Windscreen Report Form - Aviva

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A
Customer Details
Policy Number
Name
Address
Date of Birth
Phone
Mobile
Are you registered for VAT?
B
Your Vehicle
Make and Model
Registration
Year
Cubic Capacity
C The Event
Date of Breakage
Which window was broken?
Type of Glass
Eg Laminated, tinted,
toughened, heated
Repaired or Replaced?
Give brief details of the cause
D Declaration
DATA PROTECTION Hibernian Aviva General Insurance Ltd. (“we”, “us” or “our”), as data
controller, will keep the information you provide about yourself and about third parties confidential.
We may use it to advise on, provide and administer insurance products and financial services
provided by us or other Hibernian Aviva companies and sometimes with our affiliates and/or
commercial partners, in order to comply with legal obligations imposed on us. We may share the
information both inside and outside of the European Economic Area, in confidence, for these
purposes with agents or service providers we have appointed, private investigators, regulatory
organisations, other insurance and financial services companies (directly or via a central register),
other Aviva group companies, those to whom we outsource certain business operations and as
required by law. We will process this information and store it on our computer and manual record
systems
To assist in preventing, detecting and/or protecting our customers and ourselves from theft and
fraud, we may use your information to make searches of our or other Hibernian Aviva companies'
records. If you give us false information or fail to disclose information and we suspect fraud, we
will record this. We also participate in industry databases such as those operated by the Irish
Insurance Federation for the purpose of sharing of information among insurance companies as a
check against non-disclosure
From time to time, we may record your telephone calls for verification and training purposes
If you would like a copy of the details we hold about you, please write to the Regulation and
Compliance Manager, Hibernian Aviva General Insurance Ltd., One Park Place, Hatch Street, Dublin
2. Please enclose the correct fee (€6.35). You also have the right to correct any errors in the
information held about you, block certain uses or object to the processing of your personal data
Please sign this form on the next page …
Hibernian Aviva General Insurance Limited Registered in Ireland Number 3319 Registered Office One Park Place Hatch Street Dublin 2

Important: Some of the questions on this form may ask for details about your health and
convictions and the health and convictions of third parties material to this risk - please do
not send us any genetic test results. This information is important for underwriting and
claims purposes and will remain confidential. By signing the declaration below, you are
giving us permission to process these details for the above purposes, including checking
with third parties or accessing State or other official records to verify whether the details
you have given are accurate and complete. By signing below, you are confirming that you
have fully explained to each person who requires this insurance cover why we asked for
this information and what we will use it for. You are also confirming each person has
agreed to this
ONLY SIGN THE FOLLOWING DECLARATION IF YOU FULLY UNDERSTAND, AND HAVE MET, ALL OF
THE ABOVE REQUIREMENTS
Declaration
I confirm:
1. That I am giving my permission for information provided in this form to be used for the purposes
set out in the Data Protection section above
2. I have read all the answers to the questions on this form and declare them to be true and
accurate in every respect. I hereby leave in the hands of Hibernian Aviva, in accordance with the
conditions of the policy, the conduct and settlement of all claims and litigation arising out of this
incident and to which this policy applies as they think fit and without reference to me. I also
undertake to render all assistance in my power to Hibernian Aviva in the handling of this claim
Signature of Policyholder
Date
Hibernian Aviva Claims Process
We want to provide the best possible service to you in respect of your claim.
Whether you are a Hibernian Aviva customer, or a Third Party availing of our services, we
understand that you would like this matter to be finalised as quickly as possible. Our job is to
facilitate this. We would ask you to please assist us by forwarding any information or documentation
we may require to bring the matter to the earliest possible conclusion. Where further documentation
or clarification is required by us to process your claim, we will advise you of this in writing, at an
early stage.
The information you provide to us as part of your claim application will be processed [both inside and
outside of the European Economic Area] by us [and by those to whom we outsource certain business
operations] to confirm your identity, process your application and to record and cross reference
particulars of your claim in insurance industry databases for fraud prevention purposes. In certain
cases, this may involve the sharing of your information with other insurance providers and private
investigators. Guidelines for sharing of information in this regard are contained in a Code of Practice
on Data Protection for the Insurance Sector which has been approved by the Data Protection
Commissioner.
Where we need to engage the services of a loss adjuster or expert appraiser to assist in the
settlement of the claim, contact information will be given to you.
We value and rely on the advice and professionalism of all advisers appointed on our behalf. We
believe they provide an efficient, fair and impartial service in the resolution of claims. If you wish, at
your own expense, you may engage the services of an appropriate expert to act on your behalf.
If your claim involves third party damage or injury, we would welcome an opportunity to discuss the
matter directly with you, as it may be possible to resolve quickly and without lengthy procedures.
Where there is no issue in relation to liability, it is in everybody’s interests to settle the claim at the
earliest opportunity.
If you have been injured and your claim qualifies for consideration by InjuriesBoard.ie, you have the
choice to continue to deal with us directly or to engage with the Board. Details of the InjuriesBoard.ie
process and procedures can be found at www.injuriesboard.ie.
Remember that, if a claim is paid under your policy, the settlement of that claim may affect future
insurance contracts of that type. If you would like further information in this regard, please contact
your agent, broker or branch.
Please note that, for verification and training purposes, telephone calls relating to your claim may be
recorded.